Tutoring Insurance Application
The information below is to facilitate receiving
an insurance quote.
After submitting this form, an A&R representative will contact you
information which will provide you with an accurate quote. You understand
that there is no coverage in force until an application is approved.
Desired Effective Date:
Federal ID #:
- Currently Valued, Hard Copy Loss Runs if not new business
Section I - GENERAL INFORMATION
1. Date business started:
2. Has the tutoring operation had any paid or reported claims in the past three years?
3. Do you follow all employee policies and procedures recommended by
Franchisor ClubZ! in Home Tutoring?
4. Do tutors have teaching credentials?
If percentage, please provide:
5. What are the minimum qualifications for the tutors?
6. Does the owner(s) or Director have teaching credentials/background in education?
7. What are your Pro forma Financial Income/Loss Projections for the next three years?
8. What percentage of staff is Employees?
%, Independent Contractors?
9. Are Independent Contactors required to carry $1,000,000 in professional
10. Total Number of Students Enrolled:
11. AverageEstimated Daily attendance:
12. Estimated Annual Payroll: $
12. Estimated Annual Revenue: $
13. Where does tutoring take place: Office
%, Student Home:
If Other please describe:
14. If at Student Home is there at least one parent present at all times?
15. What is the estimated age range of students doing tutored:
16. Is this strictly academic tutoring?
If no, what programs do you offer?
17. Do you offer formal test preparation?
18. Do you contract with school districts?
If yes, how many are contracted for the coming year?
19. What is the number of students to be tutored in the school district?
20. Are tutors allowed to transport students in their personal vehicles?
If yes, is Personal Insurance verified and Motor Vehicle Reports checked?
21. The standard General Liability limits quoted are $1,000,000/$2,000000. Please indicate if diffenent limits required:
22. Do you want Corporal Punishment coverage?
23. Is Umbrella coverage being requested?
If yes, what limit?
If in business less than 3 years, maximum available limit is $1,000,000.
Section II - ABUSE & MOLESTATION
PLEASE NOTE: Maximum limit provided with proper controls is $1,000,000/$1,000,000
1. Do your contracts require a specific abuse limit?
If yes, what is the required limit: $
2. Does your staff (paid or volunteer) employment application include questions about whether the individual has ever been convicted for any crime, including sex-related or child-abuse related offenses?
3. Does your state permit you to do criminal background investigations?
4. Are Federal and State Criminal Background checks performed on: Staff?
5. Do you verify employment related references?
6. Do you conduct personal interviews?
7. Do you have written procedures dealing with sexual abuse?
If yes, please attach/email copy. If no, do you intend to comply with ClubZ suggested written procedures?
8. Do you have a plan of supervision that monitors staff in day-to-day relationships with clients?
If yes, is a written copy available for submission?
9. Do you have specific training for tutors on identifying and reporting incidents of sexual abuse and molestation?
10. Has your organization ever had an incident which resulted in an allegation of sexual abuse? If yes, please describe the incident including date of occurrence:
Was a claim made against the organization?
If claim, was case settled?
amount of damages paid: $
Was case taken to trial?
Section III - PROPERTY
1. Replacement cost of Business Personal Property you want to insure: $
2. Property Deductible Desired:
3. If you have an office outside of the address initially given, please provide address and advise if any tutoring is done at this location:
Automobile Non-Owned and Hired Liability
Note: This coverage is excess liability only over tutors personal insurance
Crime/Employee Dishonesty: $10,000 Money & Securities In and Out with $500 Deductible
Application Completed and Submitted By:
Best Contact Phone Number:
By checking this box you certify that the statements made on this quote
request are accurate to the best of your knowledge
ALL INFORMATION IS KEPT CONFIDENTIAL
THIS INFORMATION IS BEING SUBMITTED WITH THE EXPRESSED INTENT
OF SECURING A QUOTE FOR INSURANCE FOR ClubZ In-Home tutoring fanchises
with A&R Associates.